Patients undergoing Orthopaedic Surgical Procedures (especially joint replacement and spinal surgery), have a high risk of haemorrhage. This risk is even greater when the patient is taking anticoagulation therapy.

These guidelines were drawn up by the American College of Chest Physicians to help guide the clinician during the perioperative period. I have highlighted the sections relevant to Orthopaedic Surgery, but would urge you to read the full document before implementing any local protocols.

This article discusses the perioperative management of antithrombotic therapy and is part of the American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). The primary objectives of this article are the following: (1) to address the perioperative management of patients who are receiving vitamin K antagonists (VKAs) or antiplatelet drugs, such as aspirin and clopidogrel, and require an elective surgical or other invasive procedures; and (2) to address the perioperative use of bridging anticoagulation, typically with low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH). A secondary objective is to address the perioperative management of such patients who require urgent surgery. The recommendations in this article incorporate the grading system that is discussed in this supplement (Guyatt G et al,
CHEST
2008; 133:123S¨C131S). Briefly, Grade 1 recommendations are considered strong and indicate that the benefits do (or do not) outweigh risks, burden, and costs, whereas Grade 2 recommendations are referred to as suggestions and imply that individual patient values may lead to different management choices.

The key recommendations in this article include the following:

in patients with a mechanical heart valve or atrial fibrillation or venous thromboembolism (VTE) at high risk for thromboembolism, we recommend bridging anticoagulation with therapeutic-dose subcutaneous (SC) LMWH or IV UFH over no bridging during temporary interruption of VKA therapy (Grade 1C);

in patients with a mechanical heart valve or atrial fibrillation or VTE at moderate risk for thromboembolism, we suggest bridging anticoagulation with therapeutic-dose SC LMWH, therapeutic-dose IV UFH, or low-dose SC LMWH over no bridging during temporary interruption of VKA therapy (Grade 2C);

in patients with a mechanical heart valve or atrial fibrillation or VTE at low risk for thromboembolism, we suggest low-dose SC LMWH or no bridging over bridging with therapeutic-dose SC LMWH or IV UFH (Grade 2C).

In patients with a bare metal coronary stent who require surgery within 6 weeks of stent placement, we recommend continuing aspirin and clopidogrel in the perioperative period (Grade 1C); in patients with a drug-eluting coronary stent who require surgery within 12 months of stent placement, we recommend continuing aspirin and clopidogrel in the perioperative period (Grade 1C).

In patients who are undergoing minor dental procedures and are receiving VKAs, we recommend continuing VKAs around the time of the procedure and coadministering an oral prohemostatic agent (Grade 1B); in patients who are undergoing minor dermatologic procedures and are receiving VKAs, we recommend continuing VKAs around the time of the procedure (Grade 1C); in patients who are undergoing cataract removal and are receiving VKAs, we recommend continuing VKAs around the time of the procedure (Grade 1C).

In patients who require temporary interruption of a VKA before surgery or a procedure and require normalization of the INR for the surgery or procedure,
we recommend stopping VKAs approximately 5 days before surgery
over stopping VKAs within a shorter time interval before surgery to allow adequate time for the INR to normalize.

In patients who have had temporary interruption of a VKA before surgery or a procedure, we recommend resuming VKAs approximately 12 to 24 h (the evening of or the next morning) after surgery and
when there is adequate hemostasis
over resumption of VKAs closer to surgery.

In patients who require temporary interruption of a VKA before surgery or a procedure and whose INR is still elevated (ie, ¡Ý 1.5) 1 to 2 days before surgery, we suggest administering low-dose (ie, 1 to 2 mg) oral vitamin K to normalize the INR instead of not administering vitamin K.

In patients with a mechanical heart valve or atrial fibrillation or VTE at
high risk
for thromboembolism,
we recommend bridging anticoagulation with therapeutic-dose SC LMWH or IV UFH
over no bridging during temporary interruption of VKA therapy;
we suggest therapeutic-dose SC LMWH over IV UFH.

In patients with a mechanical heart valve or atrial fibrillation or VTE at
moderate risk
for thromboembolism,
we suggest bridging anticoagulation with therapeutic-dose SC LMWH, therapeutic-dose IV UFH, or low-dose SC LMWH
over no bridging during temporary interruption of VKA therapy; we suggest therapeutic-dose SC LMWH over other management options.

In patients with a mechanical heart valve or atrial fibrillation or VTE at
low risk
for thromboembolism,
we suggest low-dose SC LMWH or no bridging
over bridging with therapeutic-dose SC LMWH or IV UFH
(Grade 2C)
.

(In patients at high or moderate risk for thromboembolism, the recommendations reflect a relatively high value on preventing thromboembolism and a relatively low value is on preventing bleeding; in patients at low risk for thromboembolism, the recommendations reflect a relatively high value on preventing bleeding and a relatively low value on preventing thromboembolism).

Perioperative Management of Patients Who Are Receiving Bridging Anticoagulation

In patients who require temporary interruption of VKAs and are to receive bridging anticoagulation, from a cost-containment perspective we recommend the use of SC LMWH administered in an outpatient setting where feasible instead of inpatient administration of IV UFH.

This recommendation reflects a consideration not only of the trade-off between the advantages and disadvantages of SC LMWH and IV UFH as reflected in their effects on clinical outcomes (LMWH at least as good, possibly better), but also the implications in terms of resource use (costs) in a representative group of countries (substantially less resource use with LMWH).

In patients who are receiving bridging anticoagulation with therapeutic-dose SC LMWH, we recommend administering the
last dose of LMWH 24 h before surgery
or a procedure
over administering LMWH closer to surgery; for the last preoperative dose of LMWH, we recommend administering approximately half the total daily dose instead of 100% of the total daily dose.

In patients who are receiving bridging anticoagulation with therapeutic-dose IV UFH, we recommend stopping UFH approximately 4 h before surgery over stopping UFH closer to surgery.

In patients undergoing a minor surgical or other invasive procedure and who are receiving bridging anticoagulation with therapeutic-dose LMWH, we recommend resuming this regimen approximately 24 h after (eg, the day after) the procedure when there is adequate hemostasis
over a shorter (eg, < 12 h) time interval
.

In patients undergoing major surgery or a high bleeding risk surgery/procedure and for whom postoperative therapeutic-dose LMWH/UFH is planned, we recommend either delaying the initiation of therapeutic-dose LMWH/UFH for 48 to 72 h after surgery when hemostasis is secured, administering low-dose LMWH/UFH after surgery when hemostasis is secured, or completely avoiding LMWH or UFH after surgery
over the administration of therapeutic-dose LMWH/UFH in close proximity to surgery
.

(We recommend considering the anticipated bleeding risk and adequacy of postoperative hemostasis in individual patients to determine the timing of LMWH or UFH resumption after surgery instead of resuming LMWH or UFH at a fixed time after surgery in all patients)
.

Perioperative Management of Patients Who Are Receiving Antiplatelet Therapy

In patients who require temporary interruption of aspirin- or clopidogrel-containing drugs before surgery or a procedure, we suggest stopping this treatment 7 to 10 days before the procedure
over stopping this treatment closer to surgery
.

In patients who have had temporary interruption of aspirin therapy because of surgery or a procedure, we suggest resuming aspirin approximately 24 h (or the next morning) after surgery when there is adequate hemostasis
instead of resuming aspirin closer to surgery
.

In patients who have had temporary interruption of clopidogrel because of surgery or a procedure, we suggest resuming clopidogrel approximately 24 h (or the next morning) after surgery when there is adequate hemostasis
instead of resuming clopidogrel closer to surgery
.

For patients who are not at high risk for cardiac events, we recommend interruption of antiplatelet drugs.

For patients at high risk of cardiac events (exclusive of coronary stents) scheduled for noncardiac surgery, we suggest continuing aspirin up to and beyond the time of surgery; if patients are receiving clopidogrel, we suggest interrupting clopidogrel at least 5 days and, preferably, within 10 days prior to surgery.

In patients scheduled for CABG, we recommend continuing aspirin up to and beyond the time of CABG; if aspirin is interrupted, we recommend it be reinitiated between 6 h and 48 h after CABG. In patients scheduled for CABG, we recommend interrupting clopidogrel at least 5 days and, preferably, 10 days prior to surgery. In patients scheduled for PCI, we suggest continuing aspirin up to and beyond the time of the procedure; if clopidogrel is interrupted prior to PCI, we suggest resuming clopidogrel after PCI with a loading dose of 300 to 600 mg.

In patients with a bare metal coronary stent who require surgery within 6 weeks of stent placement, we recommend continuing aspirin and clopidogrel in the perioperative period. In patients with a drug-eluting coronary stent who require surgery within 12 months of stent placement, we recommend continuing aspirin and clopidogrel in the perioperative period. In patients with a coronary stent who have interruption of antiplatelet therapy before surgery, we suggest against the routine use of bridging therapy with UFH, LMWH, direct thrombin inhibitors, or glycoprotein IIb/IIIa inhibitors.

(These recommendations reflect a relatively high value placed on preventing stent-related coronary thrombosis, a consideration of complexity and costs of administering bridging therapy in the absence of efficacy and safety data in this clinical setting, and a relatively low value on avoiding the unknown but potentially large increase in bleeding risk associated with the concomitant administration of aspirin and clopidogrel during surgery).

In patients who are receiving VKAs and require reversal of the anticoagulant effect for an urgent surgical or other invasive procedure, we recommend treatment with low-dose (2.5 to 5.0 mg) IV or oral vitamin K. For more immediate reversal of the anticoagulant effect, we suggest treatment with fresh-frozen plasma or another prothrombin concentrate in addition to low-dose IV or oral vitamin K.

For patients receiving aspirin, clopidogrel, or both, are undergoing surgery, and have excessive or life-threatening perioperative bleeding, we suggest transfusion of platelets or administration of other prohemostatic agents.

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